Non-Medicare medical plan premiums (for members not enrolled in Medicare) Managed Care Plans Kaiser Foundation Health Kaiser Foundation Health Plan of Washington Plan of the Northwest Classic CDHP Classic CDHP SoundChoice Value Subscriber only $1,039.18 $907.72 $933.56 $738.98 $777.41 $919.37 Subscriber & spouse $2,072.40 $1,808.12 $1,861.16 $1,470.63 $1,548.87 $1,832.77 Subscriber & children $1,814.10 $1,597.60 $1,629.26 $1,302.30 $1,356.00 $1,604.42 Subscriber, spouse, $2,847.32 $2,439.67 $2,556.86 $1,975.63 $2,127.45 $2,517.83 & children Preferred Provider Organization (PPO) Plans Uniform Medical Plan Classic CDHP Select UMP Plus Subscriber only $831.68 $747.79 $766.61 $816.50 Subscriber & spouse $1,657.40 $1,488.26 $1,527.27 $1,627.04 Subscriber & children $1,450.97 $1,317.73 $1,337.10 $1,424.41 Subscriber, spouse, $2,276.69 $1,999.87 $2,097.76 $2,234.95 & children Medical premium surcharges (for non-Medicare subscribers only) Two premium surcharges may apply in addition to your monthly medical premium. You will be charged for them if the conditions described below apply, or if you do not attest to the surcharges when required. • A monthly $25-per-account medical premium surcharge will apply if you or any dependent (age 13 and older) enrolled in PEBB medical uses tobacco products. • A monthly $50 medical premium surcharge will apply if you enroll a spouse or state-registered domestic partner, and they have chosen not to enroll in another employer-based group medical plan that is comparable to PEBB’s Uniform Medical Plan (UMP) Classic. For more guidance on whether these premium surcharges apply to you, see the 2024 PEBB Premium Surcharge Attestation Help Sheet on the HCA website at hca.wa.gov/erb under Forms & publications. 3